CONGRESS IS broken. Except, in increasingly rare cases, when it isn’t. See, for example, a surprisingly calm and reasonable movement on Capitol Hill to eliminate surprise medical billing, a symptom of the nation’s unwieldy health-care system that saddles people with massive, unexpected financial debts stemming from the care they receive.
Too many Americans have been there. They carefully choose hospitals or clinics that are inside their insurance networks, expecting to minimize their out-of-pocket costs. Then they get hit with huge bills from, say, the doctors who anesthetized them or the radiologists who reviewed their X-rays, who are — somehow — outside their network, even though they provide services at an in-network facility. People experiencing health emergencies can have it even worse; they have no choice about the ambulances that pick them up or some of the other ancillary providers who care for them, but they have to pay their bills, regardless. Patients lack both foreknowledge about what they will be charged and the leverage to change the situation. The resulting bills can be crushing.
The blatant unfairness has moved lawmakers this year to consider acting, and the Trump administration to urge them on.
There are two major options under consideration. One, which seems to be the more popular option on the Hill, is for the government to directly regulate the prices that ancillary providers can charge. The anesthesiologist would get a payment from a patient’s insurance company equal to, say, the median payment that insurer offers specialists providing that service, while the patient would be charged no more than typical out-of-pocket costs. Or, in another formulation, the money that providers get from insurance companies could be settled by special arbiters, which would be less transparent but perhaps more acceptable to the providers. This rate-setting approach would not much threaten the business model of medical specialists, so it would encounter less opposition, yet it would still scale back the exorbitant amounts that doctors who take the most advantage of the current system currently charge.
But under this approach, medical specialists’ prices overall still might not decline as much as they should, people’s insurance premiums might remain higher than need be and the federal government might pay too much. The better approach is to require that in-network hospitals ensure that the providers to which they direct patients are also in-network, or behave as though they are. Once again, patients would encounter more reasonable out-of-pocket costs. Meanwhile, the insurers, hospitals and providers would negotiate suitable rates. This option poses more of a threat to providers’ bottom lines, and therefore could encounter more opposition. But it has more promise to drive doctors’ charges down to a fair level.
Both approaches so far have a big gap. Ambulances and air ambulances could still charge patients huge bills. That needs to be addressed in whatever bill emerges.
What cannot happen is for the momentum behind fixing these problems to wane in the midst of an election year or other unrelated political sniping. Too much sensible, bipartisan policy succumbs to such a fate.